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Sign-Up Form for the Bristol-Myers Squibb Patient Assistance Foundation

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Sign-Up Form for the Bristol-Myers Squibb Patient Assistance Foundation Sign-up Form for the Bristol-Myers Squibb Patient Assistance Foundation What is the Bristol-Myers Squibb Patient Assistance Foundation? • Bristol-Myers Squibb Company (BMS) established the Bristol-Myers Squibb Patient Assistance Foundation, Inc. (BMSPAF) to help patients who need help paying for medicines prescribed by their healthcare providers. BMSPAF is a non-profit organization that helps certain patients get, free of charge, the medicines that are listed in this application. • Patients who meet certain rules will be able to get their prescribed medicines free of charge for up to one year. Every year, you must reapply, and be accepted, to continue in the program. • Once approved, most medicine will be shipped to your home or to your healthcare provider’s office. What medications are available from the Foundation? ABILIFY® (aripiprazole) NULOJIX® (belatacept) BYDUREON® (exenatide extended-release for injectable suspension) ONGLYZA® (saxagliptin) BYETTA® (exenatide) ORENCIA® (abatacept) ELIQUIS® (apixaban) SymlinPen® (pramlintide acetate) Pen Injector TM KOMBIGLYZE XR (saxagliptin and metformin HCl extended-release) Am I able to get medication free of charge? You may be able to get medicine free of charge through the Bristol-Myers Squibb Patient Assistance Foundation if: • You are being treated as an outpatient with one of the medicines listed in this application. • You live in the USA, Puerto Rico, or the U.S. Virgin Islands. • You meet the income limits for your medicine. You will need to send your most recent Federal Tax Return or other proof of income. • You do not have insurance coverage for your BMS medicines or you are signed up for a Medicare Part D plan and have spent at least 3% of your yearly household income on out-of-pocket costs for prescription medicines this year. These are just some of the eligibility requirements - - if you meet the criteria listed here, it does not guarantee you will be accepted. How do I apply? If you think you may be able to get medicines free of charge based on the criteria above, complete the form that follows, and return it with your proof of income statement by mail or fax to: Bristol-Myers Squibb Patient Assistance Foundation PO Box 220769 Charlotte, NC 28222-0769 Phone: 800-736-0003 Fax : 800-736-1611 Don’t forget to sign the form and submit your proof of income. If you have questions about the Bristol-Myers Squibb Patient Assistance Foundation or how to fill out the form, you can get in touch with the Foundation at 800-736-0003 between 8 a.m. and 8 p.m. Eastern Time Monday through Friday. ABILIFY is a trademark of Otsuka Pharmaceutical Co., Ltd. ELIQUIS, KOMBIGLYZE, NULOJIX, ONGLYZA, and ORENCIA, are trademarks of Bristol-Myers Squibb Company. BYDUREON, BYETTA and SYMLIN are trademarks of Amylin Pharmaceuticals, LLC. NOU S13UB00168-01 02/13 NOUS13UB00168-01 02/13 NOUS13UB00168-01 02/13NOUS13UB00168-01 03/13 PO Box 220769 Charlotte, NC 28222-0769 Phone 800-736-0003 Fax 800-736-1611 SECTION I: Patient Information (to be completed by patient) Personal Information Name ____________________________________________________ Date of Birth_______/_______ / __________ First Middle Initial Last Address ___________________________________________________ City _______________ State _____ Zip _____ Home Phone (______) _______________________________ Cell Phone (______) ______________________________ Social Security Number ____________________________ Gender: Female Male Number of people in your household ________ (Include yourself, your spouse and your dependents) What is the total combined household income? $___________ per month OR $___________ per year Please include a copy of your most recent Federal Tax Return, Social Security Statement, or other documents that support the income amount provided above. If you have indicated no income ($0), your application may be subject to audit or request for additional documentation. Allergies ____________________________________________________________________________________ Medications currently taking ___________________________________________________________________ Insurance Information Do you have coverage for prescription medications through (check all that apply)? Medicaid Private Insurance State assistance program for medication Medicare A or B VA or Military Benefits None Medicare Part D If you do have coverage for prescriptions, please provide the following information. Name of Insurance Company ___________________________ Phone Number (______) ________________________ Policy Number _____________________________________ Group Number ________________________________ Please continue to the next page to read and sign the Patient Agreement and Consent. Page 2 of 4 NOUS13UB00168-01 03/13 PO Box 220769 Charlotte, NC 28222-0769 Phone 800-736-0003 Fax 800-736-1611 Patient Agreement and Consent By signing below: I promise that: • All of the information I provided in this sign-up form and the copies of the income documents or other information about me that I may provide are complete and true. • If I am approved to get free medicine (enrolled), I will not try to get reimbursed for the free medicine from anyone else, including from a prescription insurance program or any other charity. • If my insurance coverage changes in any way, I will immediately tell the Bristol-Myers Squibb Patient Assistance Foundation (BMSPAF). I give my permission to: • The BMSPAF and the companies that BMSPAF uses to administer the program for free medicine (its Administrators) to use my information, and share it with my healthcare providers, my insurance company, and other organizations or companies that might be able to help me, so that the BMSPAF and its Administrators may: • Decide if I am eligible for this program, • Help me enroll (if I am eligible) and help get the free medicine to me for as long as I am enrolled, and • Find out whether I may be eligible for, or am already enrolled in, another program (including a prescription insurance plan or another charitable program). • My insurance company and healthcare providers and others who may be helping me apply to this program to share information about me with the BMSPAF and its Administrators. I understand that: • The BMSPAF and its Administrators may ask for additional documents and information at any time, even if I am already enrolled, so that they can decide if the information on this sign-up form is complete and true. • The BMSPAF and its Administrators will only ask for the information that is needed to process my sign- up form, to help me with free medicine if I am enrolled, and to renew my sign-up form when my enrollment is going to end. • If there is missing information on my sign-up form, if I have not provided the right income documents, or if I do not respond to requests for additional documents or information, BMSPAF and its Administrators can delay my enrollment, decide I am not eligible, or stop providing me with free medicine. • The BMSPAF and its Administrators will only share my information as described on this form or as required or allowed by law. • If I am enrolled, the BMSPAF will only give me free medicine for a short time and I will have to re-do my sign-up form before my enrollment ends if I still need help with free medicine. • I have the right to revoke my promises and permissions at any time by writing to the BMSPAF at the address in this sign-up form. • If I revoke my promises and permissions, I will no longer be eligible for this program and my enrollment will end. • I may not be eligible for free medicine if I have prescription coverage that will pay for my medicine (other than Medicare Part D). • This program may be changed or stopped at any time without notice. Patient Signature: __________________________________________________ Date: ________________________ Page 3 of 4 NOUS13UB00168-01 03/13 PO Box 220769 Charlotte, NC 28222-0769 Phone 800-736-0003 Fax 800-736-1611 SECTION II: Treatment and Prescribing Information (to be completed by provider) Patient Name____________________________________ Product Requested: ABILIFY® (aripiprazole) NULOJIX® (belatacept) BYDUREON® (exenatide extended-release for injectable suspension) ONGLYZA® (saxagliptin) BYETTA® (exenatide) ORENCIA® (abatacept) ELIQUIS® (apixaban) SymlinPen® (pramlintide acetate) Pen Injector KOMBIGLYZETM XR (saxagliptin and metformin HCl extended-release) Ship to: Healthcare Provider Patient (available only for oral and subcutaneous (SC) injection medications) For oral and SC injection medications: Please attach a new prescription for the patient named above. Prescriptions may be written for up to a 1 year supply, subject to eligibility period limits. Specify the number of refills needed. Up to a 90 day supply is available at a time for oral medications, Bydureon, and Orencia. Up to a 30 day supply is available at a time for: Byetta and SymlinPen. For physician-administered Intravenous Infusion medications: Provide the following information for up to a 4-week supply** Drug Name:__________________________ BSA/Weight___________ Patient ICD-9/Diagnosis ______________ Dose(s) and Dosing Schedule/Frequency: Scheduled Administration Dates***: * If you are prescribing a patient both Orencia SC and IV, please complete both the SC and physician-administered intravenous infusion sections above. ** You will need to contact the Foundation to request orders of these medications after the initial shipment is received. *** The BMSPAF may request proof of administration of product received through this program, including flow sheets.
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